Wednesday, March 21, 2007

Gastric Bypass, Step 2

Yesterday we visited our doctor -- or as close as possible, since our previous doctor moved away and no new one has been hired for her patients yet, so a physician's assistant is handling us until a new doctor is brought on. The PA was very encouraging about the possibility of a gastric bypass. She didn't think there'd be any trouble getting insurance to consider it a medical necessity (at least, no more trouble than anything involving insurance), and she seemed little worried about the dieting requirements, considering we have 4½ years on record already. Maybe she's being a little excessively positive on that last point; I suspect the surgeons will make us jump through pointless hoops, but nothing we can't do.

Step 3 will be talking to surgeons. We got a referral for a consultation at Fletcher Allen, where we will talk to someone, probably a surgeon, about the options and what comes next, and assuming we decide to proceed (which seems likely at this point), how it'll go.

The big question still hanging in the air is whether to go for laparoscopic Roux-en-Y (of the various bariatric surgeries that are shown to reverse diabetes, this is the most common and well-known) or the Mini-Gastric Bypass (MGB). A lot of our research has showed lower complication rates and lower risk from MGB, so we've been leaning towards that, despite far greater difficulty arranging it (due to it being available only far away, the probability of far greater difficulty with insurance covering it, and the question of how to finance it).

However, we're starting to uncover some evidence contradicting that, and speculating that some complications are not being accurately recorded, because of the unusual nature of how MGBs are done (only by a few "licensed" surgeons) means some complications might be handled at different hospitals and not connected back up to the original surgeries in reviews of post-operative results.

Nothing we've found so far is truly conclusive. The most damning criticism of MGB seems to be that there have not been any truly comprehensive comparative studies contrasting it with Roux-en-Y; Dr. Rutledge, the inventory of MGB, claims that this is true only because Roux-en-Y practitioners refuse to cooperate in such a study.

And this is typical of what we've found so far; generally when you hear physicians talking about these surgeries, you get the feeling that you're hearing their personal preferences and prejudices at least as much as you're hearing the science. Personal preference and prejudice is supposed to be the patient's job in the doctor-patient relationship; the doctor is supposed to be the one dragging the patient away from spurious reasoning to scientifically-backed results.

Hopefully when we sit down with a surgeon up at Fletcher Allen we'll be able to dig through all of this. We're trying to keep open-minded about the procedures, willing to listen to the surgeon's input while at the same time insisting it be substantiated and scientific, rather than being focused on how what they happen to do at that hospital is inevitably the best treatment. ("As far as this case is concerned I have now had time to think it over and I can strongly recommend a course of leeches.")

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